RESUME KASUS

ASUHAN KEPERAWATAN PADA Tn/Ny …

DENGAN GANGGUAN SISTEM _____________ : ________________
DI RUANG POLI _________ RSUD CIMACAN CIANJUR

I. ANAMNESA
a. Identitas Diri Klien
 Nama : __________________________
 Umur : __________________________
 Jenis Kelamin : __________________________
 Alamat : __________________________
 Status Perkawinan : __________________________
 Agama : __________________________
 Suku : __________________________
 Pendidikan : __________________________
 Pekerjaan : __________________________
 Diagnosa Medis : __________________________
 Tanggal Masuk RS : __________________________
 Tanggal Pengkajian : __________________________
 Sumber Informasi : __________________________
b. Penanggung Jawab
 Nama : __________________________
 Pekerjaan : __________________________
 Hubungan Dengan Klien : __________________________

II. RIWAYAT PENYAKIT

1. Keluhan Utama Saat Masuk RS
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2. Riwayat Penyakit Sekarang
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3. Riwayat Penyakit Dahulu

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III. PENGKAJIAAN SAAT INI

1. Persepsi dan Pemeliharaan Kesehatan
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2. Pengetahuan Tentang Penyakit / Perawatan

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3. Pola Nutrisi / metabolic

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4. Pola Eliminasi
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5. Pola Aktivitas dan Latihan

Kemampuan Perawatan Diri 0 1 2 3 4
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM
Keterangan : 0 : Mandiri, 1 : Dengan Alat Bantu, 2 : Dibantu Orang Lain, 3 :
Dibantu Orang Lain Dan Alat, 4 : Tergantung Total
6. Oksigenasi
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7. Pola Tidur Dan Istirahat

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8. Pola Perceptual
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9. Pola Persepsi Diri

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10. Pola Seksualitas Dan Reproduksi

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11. Pola Peran Dan Hubungan

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12. Pola Managemen Koping Stress

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13. Sistem Nilai, Norma, Dan Kepercayaan (Pandangan Klien Tentang

Agama, Kegiatan Keagamaan , Dll)
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IV. PEMERIKSAAN FISIK

 Keluhan yang dirasakan saat ini
 TD : P: N: S:
 BB / TB :
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V. PROGRAM THERAPY

Nama Yang
Dosis Frekuensi Rute Tanggal
Obat Memberikan

VI. HASIL PEMERIKSAAN PENUNJANG DAN LABORATORIUM

VII. ANALISA DATA

No Data Penunjang Etiologi Masalah

VIII. DIAGNOSIS KEPERAWATAN

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IX. RENCANA KEPERAWATAN
DIAGNOSIS
NO TUJUAN DAN KRITERIA HASIL INTERVENSI RASIONAL
KEPERAWATAN
X. CATATAN IMPLEMENTASI
NO TANGGAL/
IMPLEMENTASI PARAF EVALUASI
DX JAM
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